Skin Tag Removal Consent Form

Skin Tag Removal Consent Form
Name

First NameLast Name
Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
About how many skin tags?
I hereby authorize Karina/Ivette of Karina's Beauty Spa to perform Skin Tag Treatments. I further authorize the skin care therapist to perform any other removal procedure that in their judgment might be necessary or advisable to achieve the successful removal of those skin growths that have approved for treatment. The details of the procedure have been explained to me in terms that i could understand. I understand that possible complications post treatment might include hyperpigmentation (lighter skin color where the growth was removed), infection if i scratched treated area before it is healed, or possible scarring if i am prone to keloids.
I understand that I will receive a Cosmetic Skin Tag Removal. In this regard, by signing this form I understand and declare the following:

1. The risks of the treatment have been explained to me. I understand that this is purely a cosmetic procedure.

2. There are risks involved in the treatment such as blood loss, scarring, infection, and thickening of the skin.

3. Post care procedures are necessary and requires my cooperation. I will follow the instructions given to me and make sure to keep with the appointments for check-ups in order to observe the progress of the treatment made.

4.There is no guarantee of results of any treatment.

5. I understand that this treatment is not recommended for diabetics, or for people with high blood pressure. I am not diabetic, nor do I have high blood pressure

6. if you have a pacemaker, are pregnant, or have a baby within the last six months you are not a candidate for this treatment. Clients with fibromyalgia and Mitral Valve prolapse will be asked to provide a release form from their physician.

7. I certified that I have no history of shingles or cold sores (herpes, virus, infection). Yes I shall see my physician for preventative treatment before receiving skin tag removal treatment.

8. The skin care therapist has answered all of my questions and has explained the most likely complication or problems that might occur during the treatment and healing And I understand them.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: